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Vaccinators being trained at the Kabuga Health Centre for the upcoming polio campaign (Kano, Nigeria, 2010).
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2011
2011 Annual Letter from Bill Gates
A
s I sit down to work on my third annual letter, governments in every corner of the world are facing tough
decisions about how to reduce spending. Although foreign aid accounts for less than 1 percent of governments’
total budgets, it is one place being considered for cuts. As a result, health and agricultural assistance that saves
lives and puts poor countries on a track for self-sufficiency is at risk.
The world’s poorest will not be visiting government leaders to make their case, unlike other constituencies, so I want to
help make their case by describing the progress and the potential I see in key areas of health and development. Perhaps
it is ironic for someone who has been so lucky to talk about the needs of those who have not.
I believe it is in the rich world’s enlightened self-interest to continue investing in foreign aid. If societies can’t provide
for people’s basic health, if they can’t feed and educate people, then their populations and problems will grow and the
world will be a less stable place.
Whether you believe it a moral imperative or in the rich world’s enlightened self-interest, securing the conditions that
will lead to a healthy, prosperous future for everyone is a goal I believe we all share.
Many people don’t have a clear image of the benefits aid actually provides. That’s not surprising, because aid covers
many different areas. Also, in the past some aid was sent to countries to buy friendship without real regard for its
impact. However, today a significant portion of foreign aid is spent on hugely beneficial programs that improve people’s
lives in both the near and long term.
Despite the threat to aid budgets, one thing that makes me optimistic about the future is the courage of leaders who are
finding ways to make the welfare of poor people a priority. Under David Cameron’s leadership, the United Kingdom
set a great example by keeping its promise to grow aid spending despite the cuts it had to make. It is inspiring to see a
leader stand up for what he believes is right, even when it isn’t easy.
Ending Polio
Aid for the poorest has already achieved a lot. For example, because of donors’ generosity, we are on the threshold of
ending polio once and for all.
Polio is a terrible disease that kills many and paralyzes others. Fifty years ago it was widespread around the world.
When you talk to people who remember polio in the United States, they’ll tell you about the fear and panic during an
outbreak and describe grim hospital wards full of children in iron lungs that maintained their breathing. At its peak in
the United States in 1952, polio paralyzed or killed more than 24,000 people.
3
Estimatednumber
Estimated numberofofpolio
poliocases
cases per
per year
year
350,000
300,000
3,500
3,000
250,000 2,500
2,000
200,000 1,500
1,000
500
150,000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
100,000
50,000
0
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
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2011
2011 Annual Letter from Bill Gates
As a result of mass mobilizations to administer the polio vaccine, polio was eliminated in the United States and most
developed nations decades ago. Most people who live in rich countries assume the disease is long gone and that it
doesn’t kill or paralyze children anymore. But it is still a frightening presence in a number of places around the world.
In 1988 the global community adopted the goal of ending polio altogether. At that time more than 350,000 children
a year worldwide were killed or paralyzed by the disease. Since then, vaccination coverage has increased significantly
and the number of cases has gone down by 99 percent, to fewer than 1,500 last year. There are now just four countries
where polio transmission has never been stopped: India, Nigeria, Pakistan, and Afghanistan.
That’s incredible progress, but the last 1 percent remains a true danger. Eradication is not guaranteed. It requires
campaigns to give polio vaccine to all children under 5 in poor countries, at a cost of almost $1 billion per year. We
have to be aggressive about continuing these campaigns until we succeed in eradicating that last 1 percent.
Therefore, funding is critical to success. Organizations such as Rotary International and the governments of India, the
United States, the United Kingdom, and Japan are all major contributors to the polio campaign. Our foundation gives
about $200 million each year. But the campaign still faces a 2011-12 funding gap of $720 million. If eradication fails
because of a lack of generosity on the part of donor countries it would be tragic. We are so close, but we have to finish
the last leg of the journey. We need to bring the cases down to zero, maintain careful surveillance to ensure the virus is
truly gone, and keep defenses up with polio vaccines until we’ve confirmed success.
W
hy is it so important to end polio? Eradication will have three huge benefits.
The first is that getting rid of polio will mean that no child will die or be paralyzed by
the disease in the future. One thing most people don’t realize is that if we don’t finish
the job on eradication, we will lose a lot of the ground we’ve gained over the past two decades.
The disease will not stay at its current low level. If we don’t get rid of it, it will spread back into
countries where it’s been eliminated, and it will kill and paralyze children who used to be safe.
Only eradication will guarantee that all children are safe.
The second benefit is that the money that will be saved by eradicating polio far exceeds what we are spending on
eradication efforts now. The long-term benefits of the last couple of billion dollars spent on eradication will be truly
phenomenal. A recent estimate added up the cost of treatment that won’t be necessary and the enhanced economic
contribution of adults who won’t get polio. Eradication could save the world up to $50 billion over the next 25 years.
The third benefit is that success will energize the field of global health by showing that investments in health lead to
amazing victories. The eradication effort illustrates so well how a major advance in the human condition requires
resolve and courageous leadership. To win these big important fights, partnerships, money, science, politics, and
delivery in developing countries have to come together on a global scale.
T
he history of polio and polio eradication is fascinating. (One of the best books I’ve read on the subject is David
Oshinsky’s Polio: An American Story.) Polio was the first disease that raised significant money from the broad
public. The March of Dimes was created to combat the disease. Although President Roosevelt and lots of
Hollywood stars helped the campaign, its huge success came from neighborhood-based fundraising. I remember March
of Dimes volunteers ringing our doorbell when I was growing up and asking for a donation. By any measure, the public’s
generosity in supporting that charity made it one of the most successful health-related fundraising campaigns ever.
The March of Dimes funded research into the first polio vaccine, which was invented by Dr. Jonas Salk and introduced
in 1955. It was such an important priority to get the polio vaccine out widely that the U.S. government sponsored the
campaign, which it had never done before. The campaigns of the late-1950s were wildly successful, and by 1961 the
number of cases in the United States was down to just 161.
A second polio vaccine—this one in the form of liquid drops that children swallow instead of an injection in the arm—
was invented by Dr. Albert Sabin and licensed in 1963. By 1979 there was no more poliovirus in circulation in the
United States. Dr. Salk’s and Dr. Sabin’s vaccines are still the key tools used for eradication today.
5
Polio timeline
3000 BC 1952 1963 1979 2007
Egyptian paintings and Worst polio outbreak Albert Sabin’s oral Last case of naturally The World Health
carvings depict people in United States polio vaccine licensed occurring polio in the Organization declares
with withered limbs history, with 58,000 United States polio eradicated in the
and walking with canes reported cases Americas, Europe, and
the Western Pacific
Clockwise, from top: Rotary vaccination teams pick up vaccines and other supplies at the Patna Junction railway station (Bihar, India, 2010). World Health Organization
workers unpack polio vaccine from boxes designed to keep it cold (Bihar, India, 2010). Billboard advertises the ongoing polio campaigns in Patna (Bihar, India, 2010).
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2011 Annual Letter from Bill Gates
To this day, the smallpox campaign is the only successful human disease
eradication campaign in history. At its peak, smallpox killed over 2 million
people every year and also blinded and disabled large numbers. The
eradication campaign started in 1967, the last naturally acquired case of
smallpox was in 1977, and the world was certified as being free of smallpox
in 1979. (Two excellent books on the smallpox eradication are Dr. D.A.
Henderson’s Smallpox: The Death of a Disease and the forthcoming House on
Fire by another key smallpox warrior, Dr. Bill Foege.)
Smallpox had a number of characteristics that made it easier to eradicate
than polio. Almost everyone who got smallpox developed a distinct rash. In
contrast most polio infections are not noticed because less than one in 100
people infected are paralyzed, even though all those infected can transmit
the virus. This means by the time a paralytic case is found, the poliovirus has
probably spread.
Also, the vaccines against polio are not as effective as the smallpox vaccine,
which was so powerful that a single vaccination protected almost everyone.
In the case of the most common polio vaccine, at least three doses are
required to get 85 percent of children fully protected. In many countries of
the developing world, even more doses are needed to reach the immunity Girl winces as she gets vaccinated against smallpox (Nigeria, 1969).
levels needed to stop transmission of the virus.
But the polio campaign also has some huge advantages that the smallpox campaign did not have. The advanced science
we have today lets us sequence the DNA of the polio virus and develop an understanding of the history of transmission,
which guides our work. We also have far better communications and modeling tools than were available in the 1970s,
and those are being used in smart ways to respond rapidly to every outbreak.
I
n 2003 I would have said we were just a couple of years away from ending polio, and I would have been wrong. That
year there were false rumors in Nigeria that the polio vaccine caused women to become sterile. This allowed the
disease to have a resurgence and to spread to many other countries. The experience of 2003 serves as a reminder to
be humble as we move forward. But humility does not mean fatalism.
Fortunately those false rumors have been almost completely eliminated through the leadership of key political and
religious figures. In 2009 when I visited Northern Nigeria to meet with the most important traditional leader, the
Sultan of Sokoto, he committed to the campaign. It was fantastic to see him publicly giving his support. (He also gave
me a horse to thank me but I told him I couldn’t take it.)
Last year both India and Nigeria had substantially fewer cases than ever before. In India the number of cases went
down from 741 in 2009 to just 41 in 2010. In Nigeria, thanks in large part to the renewed leadership in the northern
part of the country, the number went down from 388 to just 18. But alongside the phenomenal progress was another
reminder that gains can be lost without sustained action.
The majority of cases in 2010 were in countries that had been polio-free until the virus travelled back across borders
and caused outbreaks in areas where people had gotten lax about vaccination. There was a large outbreak in Tajikistan
in the first half of 2010 and another in Congo in the second half. In both regions there were a number of immunization
campaigns organized as a response. Today the outbreaks appear to be under control.
What those outbreaks in formerly polio-free countries prove is that eradication is a global project requiring every
country to do its part. Very few projects demand global participation. In most areas each country can pursue its own
approach, and countries can compare outcomes to see which approach is the most successful.
Philosopher and historian Will Durant once observed that the only thing that could get countries to join forces would
be an alien invasion. To my mind, terrible diseases are surrogates for an alien invasion. If we are to succeed, the world
needs leadership from a global institution and significant, coordinated resources from rich countries to fund activities
in the poorest countries.
7
© GAVI
Clockwise, from top left: Health worker vaccinates a woman against tetanus (Freetown, Sierra Leone, 2009). Child receives oral polio vaccine from
house-to-house vaccination team (Kano, Nigeria, 2010). Mother has her baby vaccinated against rotavirus (Corozal, Nicaragua, 2009).
Rise inmeasles
Rise in measlesvaccine
vaccine coverage
coverage andand diphtheria,
diphtheria, tetanus,
tetanus, and pertussis
and pertussis (DTP3)coverage,
(DTP3) vaccine vaccine coverage,
1980-19951980-1995
100%
90%
80%
70%
60%
50%
40%
30%
20% DTP3
10% Measles
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Source: UNICEF
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2011 Annual Letter from Bill Gates
For polio, the World Health Organization (WHO) has played the central role with Rotary International, the Centers
for Disease Control, and UNICEF as key partners. Polio eradication has benefited immensely from having Rotary’s
support. Rotary had the vision to get involved in 1985 and has kept polio eradication as its top priority. Everywhere I
go to learn about polio, I see Rotary members helping out with the hard work.
I feel sure that with continued support we will be able to show significant progress building on this year’s work. The site
www.polioeradication.org tracks the key parts of the campaign including fundraising and the latest cases. I will make
a number of trips focused on polio this year, including additional trips to India and Nigeria, and will write a report for
the foundation website. For anyone who wants to support the polio campaign, which would be fantastic, visit www.
rotary.org and click on the EndPolioNow logo.
A
few years ago I was looking into the history of vaccination
coverage. In 1980 less than 20 percent of children worldwide
received the vaccinations for diseases including measles,
diphtheria, tetanus, and whooping cough (pertussis) that children in rich
countries were receiving. Less than 15 years later, in 1995, vaccination
rates had been raised to over 70 percent. Just this year I finally got around
to learning why there was such a huge increase. The head of UNICEF
at the time, Jim Grant, led the way. The book Jim Grant—UNICEF
Visionary tells his amazing story. Since there are only a few used copies
of this in circulation UNICEF recently made a free version available at
www.unicef.org/publications/index_4402.html.
I’m surprised by how little attention his story gets and how long it took
me to find out about it. I was inspired by reading how he drove global
Jim Grant reads with a child at a community center © UNICEF
progress even during the tough economic decade of the 1980s. We can (Abidjan, Cote d’Ivoire, 1994).
draw lessons from his leadership now, in our own tough economic times.
As is often the case with courageous efforts, many people resisted Jim Grant’s push, viewing it as too top-down.
However, he managed to enlist a number of countries to lead the way, and as the number of deaths in those countries
dropped dramatically he was able to persuade almost every country to run strong vaccination campaigns. It is especially
amazing that he did this in an age when there was no Internet and no email. Jim Grant’s achievement is the greatest
miracle of saving children’s lives ever.
9
Infant being immunized at a district hospital (Dowa, Malawi, 2010).
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2011
2011 Annual Letter from Bill Gates
T
he benefits of widespread vaccination are mostly explained in terms of the lives vaccines save, and based on that
measure alone, vaccines are the best investment to improve the human condition. However, there are two other
equally important benefits that are not as widely known partly because they are harder to quantify.
The first is the reduction in sickness. I don’t mean just the acute sickness where a child is clearly suffering from the
disease, but also the permanent disabilities caused by the disease. This is most noticeable when the disability presents
with a clear symptom such as being paralyzed by polio or going deaf because of a pneumococcal infection. However,
the largest disability is the effect on mental development. For example, severe cerebral malaria damages your brain
even if you survive. When children have lots of diarrheal episodes or parasites in their intestines, they don’t get enough
nutrition for their brains to develop fully.
The huge infectious disease burden in poor countries means that a substantial part of their human potential is lost by
the time children are 5 years old. A group of researchers at the University of New Mexico conducted a study, covered in
The Economist, showing the correlation between lower IQ and a high level of disease in a country. Although an IQ test
is not a perfect measure, the dramatic effect you see is a huge injustice. It helps explain why countries with high disease
burdens have a hard time developing their economies as easily as countries with less disease.
The second great benefit of vaccination is that as the childhood death rate is reduced, within 10 to 20 years this reduction
is strongly associated with families choosing to have fewer children. While it might seem logical that saving children’s
lives will cause overpopulation, the opposite is true.
I mention this amazing connection often, since I remember how I had to hear it multiple times before the full
implications of it became clear. It is the reason why childhood health issues are key to so many other issues, including
having resources for education, providing enough jobs, and not destroying the environment. Only when Melinda and
I understood this connection did we make the full commitment to health issues, especially vaccination.
The connection of health to education, jobs, and the environment points back to the tremendous value of high-quality
international aid—and why it’s essential that donor nations not cut their spending on it. Melinda and I have committed
$10 billion from the foundation over the next 10 years to help make this the Decade of Vaccines. However, this will fall
well short of what is needed.
The group which helps poor countries purchase vaccines and increase vaccine coverage is the GAVI Alliance and like
the polio campaign its success will depend on donor generosity.
110
100
90
80
70
60
11
Bed nets to protect against malaria being manufactured at the A to Z Textile Mills (Arusha, Tanzania, 2009).
Shanti Devi holds her newborn daughter (Koelikhera Village, India, 2004). Melinda observes newborn babies at Bwaila Hospital (Lilongwe, Malawi, 2010).
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2011 Annual Letter from Bill Gates
T
he foundation’s website does a great job of outlining all of our strategies, but in the remainder of my letter I want
to highlight a few specific areas. The world has made some crucial breakthroughs, and with bold leadership I
think we can do even more.
13
Clockwise, from top left: Pregnant mother gets tested for HIV at the NDA Health Center (Dimbokro, Cote d’Ivoire, 2010). Transgender sex workers at a drop-in center
(Chennai, India, 2008). Female sex workers are trained how to use condoms at a mobile clinic (Mumbai, 2009). Sign advertises the use of condoms to prevent HIV
infection (Andhra Pradesh, India, 2009). Physician examines a six-year-old girl (Siem Reap Province, Cambodia, 2010).
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2011 Annual Letter from Bill Gates
the same condition—they were unable to breathe at birth. Sadly, it was clear that only one would survive. That baby’s
mother had made it to the donor-funded hospital in time for her delivery and was able to get the care she needed. Her
baby was immediately resuscitated, which saved his life. The other was not so fortunate. He was born on the way to
the clinic, on the side of road, and was not resuscitated soon enough. I wish everyone had a chance to experience what
Melinda did, so they could see how things are improving but also understand the urgent need to do more.
15
Lab technicians at the Diamond AIDS Research Center (New York City, 2008).
Farmer prepares dried maize (corn) for sale (Monopo, Mozambique, 2010). Farmer separates maize from stalks (Malawi, 2010). © Charlie Barnwell, World Food Programme
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2011 Annual Letter from Bill Gates
basis to block infection. A PrEP trial showed a strong prevention benefit for the participants who consistently used the
drugs and a weaker impact when all the participants were included. With both microbicides and PrEP I think countries
with large epidemics should figure out how to do large community trials as soon as possible. This would shorten the
time before all patients have these lifesaving tools by many years.
If the United States had an epidemic where almost half the girls in large neighborhoods contracted a terrible disease, we
would find a way to cut through all the complexity. With HIV it is more difficult since there are many countries involved.
But we need to work creatively to shorten these delays.
The best tool would be a vaccine for HIV. The scientific progress on this has gone well. The positive results of the trial
in Thailand were a turning point for the field, and blood samples from the volunteers are being studied in depth for
lessons about why that vaccine worked but only to a limited degree.
There has also been an explosion in the discovery of antibodies that block HIV infection. Scientists don’t yet know how
to make a vaccine that will cause patients to generate lots of these antibodies, but there are several approaches that look
promising and will be ready to go to trials in the next few years.
In order to get a fully effective HIV vaccine we will almost certainly need several rounds of trials where we learn and
improve the candidate vaccines. So to get a vaccine as soon as possible we need to minimize the length of the trials and
the time between trials. So far each cycle has taken over five years. The field needs to look into how to shorten this so
that progress matches the urgency of the problem.
17
Selected countries’ performance in mathematics, reading, and science, 2009
Geoffrey Canada talks with students at Harlem Children’s Zone, in a scene from Waiting for “Superman” (New York City, 2009). © Paramount Pictures/Participant Media
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2011 Annual Letter from Bill Gates
Excellence in Teaching
In the United States, the foundation’s biggest investments are in education. Only a third of students
are graduating from high school prepared to succeed at college-level work, and even fewer are
going on to get a degree that will help them compete for a good job. No one should feel comfortable
with those results.
Davis Guggenheim’s amazing and popular movie Waiting for “Superman” made a powerful
argument against the status quo. It showed a broad audience that schools with the right approach can succeed, even
with inner city students that typical schools do not educate well. As more people understand the gap between what is
possible and what is actually happening in most schools, I believe the momentum for reform will grow.
Since 1980 U.S. government spending per K-12 student increased by 73 percent, which is 20 percent faster than the rest
of the economy. Over that time our achievement levels were basically flat, while other countries caught up. A recent
analysis by the Programme for International Student Assessment (PISA) showed the United States is about average
(compared to 35 developed countries) in science and reading and below average in math. Many Americans have a hard
time believing this data, since we are so used to being the global leader in educational achievement and since we spend
a lot more money on education than many other countries.
PISA measured educational achievement in the Shanghai area of China, and even allowing for the fact that Shanghai is
one of the most advanced parts of China, the scores relative to the United States and other countries were quite stunning.
China did better in math, science, and reading than any of the 65 countries it was compared to, and it achieved these
results with an average class size of more than 35 students. One of the impressive things about the Chinese system is
how teachers are measured according to their ability. There are four levels of proficiency in the Chinese system, and to
move up a level, teachers have to demonstrate their excellence in front of a panel of reviewers.
According to the PISA analysis (available at www.pisa.oecd.org), two key things differentiate the U.S. education system
from most other countries’ systems. The first is that non-U.S. students are in school for more hours, and the second is
that U.S. school systems do very little to measure, invest in, and reward teacher excellence.
Most people who become teachers do so because they’re passionate about kids. It’s astonishing what great teachers can
do for their students. But the remarkable thing about great teachers today is that in most cases nobody taught them
how to be great. They figured it out on their own. That’s why our foundation is investing to help devise measurement
and support systems to help good teachers become great teachers.
Our project to learn what the best teachers do—and how to share this information with other teachers—is making
significant progress. With the help of local union affiliates, we have learned a lot already. We’re learning that listening to
students can be an important element in the feedback system. In classes where students agree that “Our class stays busy
and doesn’t waste time” or that “In this class, we learn a lot almost every day,” there tend to be bigger achievement gains.
Another great tool is taking a video showing both the teacher and
the students and asking evaluators to provide feedback. Melinda
and I spent several days visiting schools in Tennessee this fall
and sat with teachers who were watching videos of themselves
teaching. We heard from a number of them how they had already
improved by seeing when students were losing interest and
analyzing the reasons.
Ultimately, the goal is to gather high-quality feedback from
multiple sources—test scores, student surveys, videos, principals,
and fellow teachers—so that teachers know how to improve. I
think it is clear that a system can be designed that teachers agree
is fair, has modest overhead, and rewards the teachers who are
doing the most for their students.
State budgets, the biggest part of K-12 funding, will be challenged
in the years ahead because of the economic downturn, the liabilities
from early retirement and pension commitments, and increasing Visiting the Ridgeway Middle School with Melinda to learn about the
medical costs. I recently gave a speech to the chief state school officers Measures of Effective Teaching project (Memphis, Tennessee, 2010).
19
Welding student Jaurie Vaughn at the Tennessee Technology Center (Nashville, Tennessee, 2010).
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2011
2011 Annual Letter from Bill Gates
(www.gatesfoundation.org/ccsso) about how they might need to find money to reward excellent teaching by shifting
some away from things like payment for seniority or advanced degrees that do not correlate with improved teaching.
I am very enthusiastic about the potential of innovation to help solve many of the problems with our education
system. Melinda and I were impressed when we visited the Tennessee Technology Center in Nashville, an institution
that provides young adults with technical training and certificates. It gets significantly better results than its peer
institutions—graduating 71 percent of its students—because it focuses on teaching job skills that are in high demand
and is oriented around meeting the needs of students who are juggling school with work and family. Sometimes
something as simple as rethinking the times when classes are scheduled makes a huge difference for students.
The foundation is funding the development of online tools to help both K-12 and college students learn. Pioneers like
Sal Khan are already showing how effective online tools can be. His website www.khanacademy.org continues to grow
its library of 2,000 short instructional videos on topics from basic arithmetic to complicated subjects like biology and
physics. The videos are a tremendous resource for students of any age.
Sal’s vision for how technology can improve learning is broader than just videos. With support from the foundation, he’s
been able to expand his site to include online exercises that diagnose weak spots, pointing you to additional material
to fill the gaps in your knowledge. Also, Khan Academy is creating an online “dashboard” to help teachers use the site
as part of their curriculum. The dashboard tells the teacher how each student is doing, pinpoints where they’re having
trouble, and suggests explanations and exercises to help.
Although it is clear that online learning works for strongly motivated students, we need to learn how to blend classroom
learning and online learning, particularly for younger and less-prepared students. As these projects develop and we
start to answer many of these questions, I believe technology will let us dramatically improve education despite the
budget constraints.
21
Clockwise, from top left: Geetanjali in her bakery with her son and daughter (New Delhi, 2010). Woman carries maize to market (Kunsu, Ghana, 2010). Kamla Devi at her
roadside flower shop (New Delhi, 2010). Child receives oral polio vaccine (Kano, Nigeria, 2010). Students learn about biotech in Dr. Kinchington’s 10th grade class at the
Science and Technology Academy (Pittsburgh, Pennsylvania, 2010).
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2011
2011 Annual Letter from Bill Gates
Bill Gates
Co-Chair, Bill & Melinda Gates Foundation
January 2011
23
Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead
healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift
themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those
with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle,
Washington, the foundation is led by CEO Jeff Raikes and Co-chair William H. Gates Sr., under the direction of Bill and
Melinda Gates and Warren Buffett. Learn more at www.gatesfoundation.org.
© 2011 Bill & Melinda Gates Foundation. All Rights Reserved. Bill & Melinda Gates Foundation is a registered trademark in the United States and other countries.